advanced periodontal diagnostic techniques mine

ADVANCED PERIODONTAL DIAGNOSTIC TECHNIQUES

Dr MIDHUN KISHOR S

I

DIAGNOSIS

Diagnosis is defined as; correct determination, discriminative estimation and logical appraisal of conditions found during examination by distinctive marks, signs and characteristics of diseases

Diagnosis can be defined as the art of identifying a condition or disease and differentiating it from other entities

Text book of Carranza's clinical periodontology, Second south Asia Edition

Diagnosis is defined as an utilisation of scientific knowledge for identifying a disease process and to differentiate it from other diseased process

Types of diagnosis

Provisional Therapeutic Differential Comprehensive Emergency

DIAGNOSTIC AIDS IN PERIODONTICS

CONVENTIONAL

ADVANCED

Current conventional techniques

Clinical diagnosis is made by measuring either

clinical attachment loss (CAL) or radiographicallyby loss of alveolar bone

This kind of evaluation identify and quantify

current clinical signs of inflammation

Provides historical evidence of damage with

its extent and severity

STATUS of current conventional methods

POSITIVES

They can be performed swiftly with minimum equipment and effort and are

in expensive

Epidemiologic surveys can be carried out easily and the results are usually a true representation

of the periodontal status of population

Diagnostic techniques in periodontology: a historical review STEVENI. GOLD Periodontology 2000, Vol. 7, 1995, 9-21

NEGATIVES

• Does not provide cause of the condition, EXACT etiology cannot bedetermined

• No info. on patient’s susceptibility to the disease

• Cannot identify sites with ongoing periodontal destruction or sites inremission

• No reliable markers of current diseases activity

• Difficult to determine the prognosis accurately and to perform anappropriate treatment

Diagnostic techniques in periodontology: a historical review STEVENI GOLD Periodontology 2000, Vol. 7, 1995, 9-21

Advanced periodontal diagnostic techniques


Advances in clinical diagnosis

GINGIVAL BLEEDING

• Indicator of inflammatory lesion

• Relation to disease activity is unclear.

• Normal probing force is 0.25N

• Presence is not an indicator but absence indicates health.

Gingival temperature

• Kung et al (1990) claim that thermal probes are sensitive diagnostic devices for measuring early inflammatory changes in gingival tissue.

• Subgingival temperature at diseased sites is increased as compared to normal healthy sites

• Commercially available system PerioTemp probe enables the calculation of temperature differential (with sensitivity of 0.10C) between the probed pocket and subgingival temperature

Kung RT, Ochs B, Goodson JM: Temperature as a periodontal diagnostic. J Clin Periodontol 1990; 17:557

• Possible explanation for increase temperature with increasing probing depth is an increase in cellular and molecular activity caused by increased periodontal inflammation

• Haffajee et al. (1992): found that elevated subgingival site temperature is related to attachment loss in shallow pockets and elevated proportions of Pg, Pi, Tf, Aa

• Smokers have differences in sub gingival temperature and sublingual temperature

Periodontal probing

• Most widely used diagnostic tool

• Probing depth is measured from the free gingival margin to the depth of the probeble crevice.

• Longitudinal measurement of CAL or probing depth is a ‘gold standard’ for recording changes in periodontal status

Limitation of conventional probing

Lack of sensitivity and reproducibility.

Disparity between

measurement depends on:

probing technique,

probing force, angle of

insertion of probe, size of

probe, precision of calibration,

presence of inflammation.

Readings of clinical pocket

depth measured with probe does

not coincide with the histologic pocket depth.

All these variable contribute to the

large standard deviations (0.5-

1.3 mm) in clinical probing results

Classification of periodontal probesdepending on generation

1.First generation probes: (conventional probes)

Conventional manual probes that do not control probing force or pressure and that are

not suited for automatic data collection.

Williams periodontal probe CPITN probe UNC-15 probe Goldman Fox probe

Comparison of a Conventional ProbeWith Electronic and Manual Pressure Regulated Probes. Dorothy A. Perry," Edward J. Taggart/ Angela Leung/ and Ernest Newbrurt J Periodontol 1994; 65:908-913

2.Second generation probes: (Constant force probes)

• Study done by Tupta et. Al ,Hunter (1994) has shown that

• force to probe pocket: 30g

• force to probe osseous defect: 50g

• Introduction of constant force or pressure sensitive probes allowed for improved standardization of probing.

e.g.: Pressure sensitive probe

Constant pressure probe

• Limitation: data readout and storage is inaccurate

• 3.Third generation probe:(Automated probes)

• Computer assisted direct data capture was an important step in reducing examiner bias and also allowed for generation of probe precision. (according to NIDCR criteria)

• Toronto probe

• Florida probe

• Inter probe

• Foster Miller probe.

FLORIDA PROBE

• Tip is 0.4mm

• Sleeve- edge provides reference to make measurements

• Coil Spring; provides constant probing force

• Computer for data storage

Comparison of a Conventional Probe With Electronic and Manual Pressure RegulatedProbes. Dorothy A. Perry," Edward J. Taggart/ Angela Leung/ and Ernest Newbrurt J Periodontol 1994; 65:908-913.

FP Hand piece tip with constant force in use (tip at bottom of sulcus) and sleeve properly positioned at the top of thegingival margin allowing the computerto measure the difference (3.0 mm).

FP Handpiece tip as it enters the sulcus

• Clark and Yang (1992): trained operators and performing the ‘double pass’ method, the measurements taken with Florida probe system shows lower standard deviation than those obtained with conventional probing.

• Mean Standard Deviation for CAL of about 0.3mm, which is superior to an average of 0.82mm reported by Haffajee et al. For conventional probing.

Disadvantages of Florida probe.Lack of tactile sensitivityFixed probing forceUnderestimation of deep periodontal pockets

Description and clinical evaluation of a new computerized periodontal probe-the Florida Probe –journal of clinical periodontology Volume 15, Issue 2 February 1988 Pages 137–144

• 4.Fourth generation probes: (Three dimensional probes) (WATTS 2000)

• Currently under development, these are aimed at recording sequential probe positions along a gingival sulcus.

• An attempt to extend linear probing in a serial manner to take account of the continuous and three dimensional pocket that is being examined.

• 5.Fifth generation probe: (3D + Noninvasive)

• Basically these will add an ultrasound to a fourth generation probes.

• If the fourth generation can be made, it will aim in addition to identify the attachment level without penetrating it.

• e.g.: Ultra sono graphic probe.

Advances in Radiographic Assessment• Dental Radiographs are traditional method to assess destruction of alveolar bone.

• “Conventional radiographs are very specific but lack sensitivity”

• Primary criterion for bone loss is the distance from CEJ to the alveolar crest and distance more than 2 mm is considered as the bone loss.

• But variability affecting conventional radiographic technique are,

Variation in projection geometry

Variation in contrast and density

Masking by other anatomic structures.

Radiographic diagnosis in Periodontics MARJORIKE. JEFFCOAT, I.-CHUNGW ANG& MICHAELS. REDDY Periodontology 2000, Vol. 7, 1995, 54-68

Digital radiography

• Capturing radiographic image using a sensor

• The first direct digital imaging system, RadioVisioGraphy (RVG), was invented by Dr. Frances Mouyens.

• Advantages

Elimination of chemical processing

Increased efficiency and speed of viewing

Diagnostic information can be enhanced

Computerized storage of radiographs

Reduced exposure to the radiation

Fundamentals of periodontics- WILSON and KORMAN

Uses a Charge Couple Device (CCD) or CMOS sensor linked with fiber optic or other wires to computer system

CCD receptor is placed intra orally as traditional films ,images appear on a computer screen which can be printed or stored


Subtraction radiography

• Subtraction radiography was introduced to dentistry in 1980 by Ruttimann, Webber et & Grondahl HG

• This is a technique by which images not of diagnostic value in a radiograph, are eliminated so that changes in the radiograph can be precisely detected


• This technique requires a paralleling technique to obtain a standardize geometry and accurate super imposable radiographs

• This technique facilitates both quantitative and qualitative visualization of even minor density changes in the bone

• Bone gain appears as light areas and bone loss appears as dark areas

• Rethman et al.(1985): increased detectability of small osseous lesions by substraction method compared with conventional radiography

Recent image subtraction:“diagnostic

subtraction radiography” (DSR)

Modification

Use of a positioning device during film exposure

Image analysis software system applies an algorithm to correct

angular alignment discrepancies.

Ortmann (1994)- 5% of bone loss can be detected.

Diagnostic subtraction radiography (DSR) can be used

for enhanced detection of crestalor periapical bone density

changes and to evaluate caries progression

Computer Assisted Densitometric Image Analysis (CADIA)

• Video camera measures the light transmitted through radiograph and the signals form the camera is converted to gray scale image.

• Camera is interfaced with an image processor

• Advantage

• Measures quantitative changes in bone density longitudinally.

• Higher sensitivity, reproducibility and accuracy as compared to DSR.

Computed tomography (CT)

• In 1972, Godfrey Hounsfield announced the invention of a revolutionary imaging

technique, which he referred to as “computerized axial transverse scanning”

• Fan shaped X-ray source is used

• The computed tomographic image is reconstructed by computer, which

mathematically manipulates data obtained from multiple projections.

• Computed tomography is a specialized radiographic technique that allows

visualization of planes or slices of interest

Textbook Of Dental & Maxillofacial Radiology 2nd Edition by Karjodkar

Advantages over conventional radiography

• eliminates the super imposition of images of structures superficial or deep to the area of interest.

• Because of inherent high contrast resolution, differences may be distinguished between tissues that differ in physical density by less than 1%.

• multiple scans of a patient may be viewed as images in the axial, coronal, or sagittal planes depending on the diagnostic task, referred to as multi planar imaging.

Application of CT• Used when accurate information regarding the topography of osseous

structure is needed

• Soft tissue contour and dimension

• To check continuity and density of the cortical plates

• vertical height of the residual alveolar ridges

• density of the medullary space and basilar bone

• when determining how much space is available above the mandibular canal or amount of bone below maxillary sinus to receive a dental implant or whether there is a space occupying lesion in the maxillofacial region.


Disadvantages of Computed Tomography

• specialized equipment and setting.

• Radiologists and Technicians need to be knowledgeable of the anatomy, anatomic variants and pathology of the jaws

• higher radiation

• Metallic Restorations can cause ring artifacts that impair the diagnostic quality of the image

HELICAL CT

Introduced in 1989

The gantry containing x ray tube and detectors continuously revolve around the patient ,where as patients table advances through the gantry.

Result is acquisition of a continuous helix of data.

Cone-beam Computed Tomography

• Routine use of CT in dentistry is not accepted due to its cost, excessive radiation, and general practicality.

• In recent years, a new technology of cone-beam CT (CBCT) for acquiring 3D images of oral structures is now available to the dental clinics and hospitals.

• It is cheaper than CT, less bulky and generates low dosages of X-radiations.

• The innovative CBCT machine designed for head and neck imaging are comparable in size with an ortho pantomogram.


ADVANTAGES

• It gives complete 3D reconstruction

• CBCT units reconstruct the projection data to provide inter relational images in three orthogonal planes (axial, sagittal, and coronal).

• Its beam collimation enables limitation of X-radiation to the area of interest.

• Patient radiation dose is five times lower than normal CT, as the exposure time is approximately 18 seconds, that is, one-seventh the amount compared with the conventional medical CT.

• Reduced image artefacts

Indications of CBCT Evaluation of the jaw bones which

includes the following:

Bony and soft tissue lesions

Periodontal assessment

Soft tissue CBCT for the measurement of gingival tissue and the dimensions of the dentogingival unit

Alveolar bone density measurement

Temporomandibular joint evaluation

Implant placement and evaluation

Whenever there is need for 3D reconstructions

INTERFACE CONE-BEAM CT MANAGEMENT SOFTWARE

CT vs CBCT

Conventional CT scanners make use of a fan-beam and Provides a set of consecutive slices of image

Conventional CT makes use of a lie-down machine with a large gantry.

Greater contrast resolution &More discrimination between different tissue types (i.e. bone, teeth, and soft tissue)

Utilize a cone beam, which radiates from the x-ray source in a cone shape, encompassing a large volume with a single rotation.

a sitting-up machine of smaller dimensions

Commonly used for hard tissueEase of operationDedicated to dentalBoth jaws can be imaged at the same time

Lower radiation burden

OTHER NEWER TECHNIQUES

• Micro Computed Tomography

• Denta scan -pre-operative planning of endosseous dental implants and subperiosteal implants

• SIMPLANTS-Computer program for assessing oral implant site

• TACT-tuned aperture CT

• BONE SCANNING or RADIONUCLIDE IMAGING-technique assesses biochemical alteration in body , It Is a nuclear scanning test that identifies new areas of bone growth or breakdown.

Advances In Microbiologic Analysis

Uses of microbiologic analysis

1. support diagnosis of various Periodontal disease

2. Can tell about initiation & progression

3. To determine which periodontal sites are at high risk for active destruction

4. Can also be used to monitor Periodontal therapy

Diagnosis of periodontal disease based on analysis of the host Response B. LAMSTER & JOHN T. GRBIC Periodontology 2000, Vol. 7, 1995, 83-99C

Advances In Microbiologic Analysis includes:1. Immunohistodiagnostic methods

2. Enzymatic methods

3. Molecular biology techniques

• Nucleic acid probes

• Checkerboard DNA-DNA hybridization

• PCR

Sample collection

• It is a common need of all the microbiologic analysis to collect an

appropriate subgingival plaque sample

• Mombelli et al. (2002) have shown that four individual subgingival

specimens, each from the deepest periodontal pocket in each quadrant,

should be pooled to be able to detect the highest amount of pathogens.

• Transport the specimen in an anaerobic environment

IMMUNODIAGNOSTIC METHODS

• Immunological assays use fluorescent conjugated antibodies that recognizespecific bacterial antigens, and the identification of these specific antigen-antibody reactions allows the detection of target microorganisms.

• This reaction can be visualized using a variety of techniques and reactions:

1. Direct (DFA) and indirect (IFA) immunofluorescent assays

2. Flow cytometry

3. Enzyme-linked immunosorbent assay (ELISA)

4. Latex agglutination

Page RC: Host response tests for diagnosing periodontal diseases. J Periodontol 1992; 63:356.

Immunofluorescent assays

• Direct IFA: AB conjugated with Fluorescein marker + Bacteria ( Antigen) =

Immuno complex

• Indirect IFA: Primary AB + Bacteria= Immune Complex+ Secondary Fl

conjugated AB

Flow cytometry

• Rapid identification

• Laser or impedence type

• Principle is labelling bacterial cells with both species-specific antibody and a

second fluorescein-conjugated antibody

• This suspension is introduced into flowcytometer, which separates bacterial

cells into an almost single cell suspension

• Limitation is sophistication and cost involved with this procedure


ELISA= Enzyme Linked Immunosorbent Assay

ELISA has been used primarily to detect serum antibodies to periodontal

pathogens.

In research studies to quantify specific

pathogens in subgingival samples

A novel chair side ELISA commercially known as “Evalusite” has been marketed

in Europe and Canada for the chair side detection of 3 periodontal pathogens. Aa,

Pg and Pi

Latex agglutination

Test +ve

MERITS

Quantitative estimate of target species

Not requiring stringent sampling and transport methodology

Higher sensitivity and specificity

DEMERITS

Limited to number of antibodies tested

Not amenable for antibiotic susceptibility

Enzymatic Methods

• Bacteria release specific enzymes. Certain group of species share common enzymatic profile.

• e.g. Tf, PG, Td, and Capnocytophagea species release trypsin like enzyme

Trypsin like enzyme BANA hydrolysis

β-naphthylamide(chromophore)

PERIOSCAN uses this reaction for the identification of this bacterial profile in plaque

isolates

Loesh et al. (1986) detection of these periodontal pathogens by BANA reaction

serves as a marker of disease activity

He also showed that shallow pockets exhibited 10% positive BANA reaction, whereas deep

pockets (7mm) exhibited 80%-90% +ve BANA reaction

Beck et al. (1995) used BANA

test as a risk indicator for periodontal attachment loss

ADVANTAGES

• May be positive in clinically healthy site

• Can not detect sites undergoing periodontal destruction

• Limited organisms detected

• So that, negative results does not rule out the presence of other important periodontal pathogens.

Molecular Biology Techniques

• The principles of molecular biology technique reside in the analysis of DNA, RNA and the structure and function of proteins

• Diagnostic assays require specific DNA fragment that recognize complementary-specific DNA sequences from target microorganisms

• This technology requires bacterial DNA extracted from the plaque sample and amplification of the specific DNA sequence of the target pathogen

Socransky SS, Haffajee AD, Smith C, Martin L, Haffajee JA, Uzel NG, Goodson JM. Use of checkerboard DNA-DNA hybridization to study complex microbial ecosystems. Oral Microbiol Immunol 2004;19:352-362

1. Nucleic acid probes

• A probe is a known, single stranded nucleic acid molecule (DNA or RNA) from a specific pathogen synthesized and labelled with an enzyme of a radio isotope

• Hybridization: Pairing of complimentary strands of DNA to produce a double stranded DNA.


Hybridization

Probe DNA

• DMDx and Omnigene are commercially available genomic probes for the detection of Aa, Pg, Pi and Td.

• Van Steenberghe et al. (1999) reported a sensitivity of 96% and specificity of 86% for Aa., and 60% and 82% respectively for Pg in pure lab isolates.

• In clinical specimens, both sensitivity and specificity were reduced significantly, suggestive of cross reactivity with non target bacteria in plaque sample because of the presence of homologues sequences between different bacterial species

Checkerboard DNA-DNA hybridization technology

• Developed by Socransky et.al in 1994

• 40 bacterial species can be detected using whole genomic digoxigenin-labeled DNA probes.

• Applicable for epidemiologic research and ecological studies


Polymerase chain reaction (PCR)

• Repeated cycles of oligonucleotide (primer)–directed DNA synthesis of “target sequences” are carried out in vitro.

• The PCR method is considered the fastest and most sensitive method available for detecting the presence of bacterial DNA sequences

• A modification of the original PCR technology, "real-time" PCR, permits not only detection of specific microorganisms in plaque, but also its quantification.

• Advantages

• High detection limit. As less as 5- 10 cells can be amplified and detected.

• Less cross reactivity under optimal conditions

• Many species can be detected simultaneously

• Disadvantage

• Small quantity needed for reaction may not contain the necessary target DNA

• Plaque may contain enzymes which may inhibit these reactions.

Biochemical test kits

• Biochemical test kits used in periodontics analyze the gingival crevicularfluid (GCF).

• Since this fluid is derived from periodontal tissues, evaluating its constituents such as host-derived enzymes, inflammation mediators and extracellular matrix components may provide early signs of alterations.

CHAIRSIDE DIAGNOSTIC TEST KITS IN PERIODONTICS - A REVIEW by Sachin Malagi ,IAJD ,Vol 3

PERIO 2000

This test kit was released in the year

1993.

It detects elevated levels of MMPs in

the gingival crevicular fluid such

as the elastases.

The GCF is collected onto the

filter paper strip impregnated with a known amount

of buffered elastase substrate

labeled with a fluorescent indicator.

Elastase on the test strip cleaves

the substrate during the

reaction time of 4-6 minutes and

releases the indicator, visible

under fluorescent light.

Elastase is released from the lysosomes

of polymorphonuclear

leucocytes which accumulate at sites

of gingival inflammation.

The levels of these enzymes in

GCF have been noted to increase

with the development of gingivitis as well

as sites of established

periodontitis


PERIOGARD

PerioGard is based on the detection of an enzyme called aspartate

aminotransferase(AST). AST is a soluble intracellular cytoplasmic

enzyme that is released from within the cell upon its death. Since cell

death is an important part of periodontal pathogenesis,

AST levels in GCF have great potential as markers of early periodontal tissue destruction. Elevated total AST levels

in a 30-second sample have been positively associated with disease-

active sites in contrast to inactive sites


The test involves collection of GCF with the filter paper strip

which is then placed in trimethamine hydrochloride

buffer.

A substrate reaction mixture containing 1-aspartic and α-keto-

gluteric acid is added to the sample and allowed to react for ten

minutes. In the presence of AST, the Aspartate and α-keto-gluteric acid are catalyzed to oxaloacetate and

glutamate.

The addition of a dye such as fast red results in a colorproduct,the intensity of

which is proportional to the AST activity in the GCF

sample

POCKET WATCH

• The Pocket Watch was developed as a simple method of analyzing AST at the chairside .

• The principle of this test is that, in the presence of pyridoxal phosphate, AST catalyzes the transfer of an amino group of cysteine sulfuric acid by α- keto- glutericacid to yield β-sulfinylpyruvate.

• Glutamate β-sulfinyl pyruvate spontaneously and rapidly decomposes

• The sulphite ion instantaneously reacts with malachite green (MG), simultaneously causing MG to convert from a green dye to its colorless form, thereby allowing the pink–colored rhodamineB dye to show through.

• The rate of conversion of MG is directly proportional to AST concentration. However, components of the extracellular matrix and its dissolved products are present in GCF of destructive pockets, and they may release sulfide ions.


• PST® genetic susceptibility test

• Periodontal susceptibility test (PST®) is the first and only genetic test that analyzes two interleukins (IL-1α and IL-1β) genes for variations.

• IL-1 genetic susceptibility may not initiate or cause the disease but rather may lead to earlier or more severe disease.

• The IL-1 genetic test can be used to differentiate certain IL-1 genotypes associated with varying inflammatory responses to identify individuals at risk for severe periodontal disease even before the age of 60.


• Clinically, PST is used in

• New periodontal patients to assist in developing treatment plans.

• Patients requiring extensive periodontal and/or implant therapy to determine prognosis, improve patient acceptance and optimize treatment outcomes.

• Smoking patients as an additional incentive for smoking cessation.

• This discussion directly translates into improved periodontal therapy by offering the clinician, the radiographic & laboratory measure of periodontal infection as an adjunct to traditional clinical indices of periodontal disease.

• Future application of advanced diagnostic techniques will be of value in documenting disease activity and treatment options

• But, despite excellent progress in diagnostic methodology,conventionalefforts evaluating inflammation and past evidence of tissue breakdown remain the standard for disease evaluation

COMMON COMMERCIAL DIAGNOSTIC AIDS AND THEIR USES

PERIOTEMP - GINGIVAL TEMPERATURE

PERIOTEST - TOOTH AND IMPLANT MOBILITY

OSSTELL APPARATUS - IMPLANT MOBILITY

PERIOSCOPY - DETECTION OF CALCULUS

KEYLASER3 - DETECTION AND REMOVAL OF CALCULUS

PERIOSCAN - DETECTION OF BANA ORGANISMS

HALIMETER - HALITOSIS

DIGORA - DIGITAL RADIOGRAPHY

NEWTOM QR-DVT - CBCT

ULTRADENT - ULTRASONIC IMAGING

PERIOCHECK - NEUTRAL PROTEINASE

PROGNOSTIK ,BIOLISE - ELASTASE

PERIOGUARD - AST

POCKET WATCH - AST

TOPAS - BACTRIAL TOXINS AND PROTEASES

MICRODENT TEST - PCR for Pg,Aa,Tf,Td

My PERIO PATH - RT-PCR

My Perio ID - Genetic susceptibility test

OMNI GENE - NUCLEIC ACID PROBE

REFERENCES

• Socransky SS, Haffajee AD, Smith C, Martin L, Haffajee JA, Uzel NG, Goodson JM. Use of checkerboard DNA-DNA hybridization to study complex microbial ecosystems. Oral Microbiol Immunol 2004;19:352-362

• Periodontology 2000. Vol. 7, 1995

• CHAIRSIDE DIAGNOSTIC TEST KITS IN PERIODONTICS - A REVIEW by Sachin Malagi ,IAJD ,Vol 3

• Text book of Carranza's clinical periodontology, Second south Asia Edition

• Kung RT, Ochs B, Goodson JM: Temperature as a periodontal diagnostic. J Clin Periodontol 1990; 17:557

• Host response tests for diagnosing periodontal diseases. J Periodontol 1992; 63:356.

Host response tests for diagnosing periodontal diseases. J Periodontol 1992; 63:356.

Description and clinical evaluation of a new computerized periodontal probe-the Florida Probe –journal of clinical periodontology Volume 15, Issue 2 February 1988 Pages 137–144

Loesche WJ: The identification of bacteria associated with periodontal disease and dental caries by enzymatic methods. Oral Microbiol Immunol 1986; 1:65.

Comparison of a Conventional ProbeWith Electronic and Manual Pressure RegulatedProbes. Dorothy A. Perry," Edward J. Taggart/ Angela Leung/ and Ernest NewbrurtJ Periodontol 1994; 65:908-913



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advanced periodontal diagnostic techniques mine

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